Anticonvulsant activity of steroids

ABSTRACT

The present invention relates to methods of preventing, inhibiting, delaying, and/or mitigating seizures by administration of a steroid, e.g., a neurosteroid, e.g., allopregnanolone.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.14/646,886, filed on May 22, 2015, which is a U.S. national phaseapplication under 35 U.S.C. § 371 of International Appl. No.PCT/US2013/072351, filed on Nov. 27, 2013, which claims the benefitunder 35 U.S.C. § 119(e) of U.S. Provisional Application No. 61/732,252,filed on Nov. 30, 2012, all of which are hereby incorporated herein byreference in their entireties for all purposes.

FIELD

The present invention relates to methods of preventing, inhibiting,delaying, and/or mitigating seizures by administration of a steroid,e.g., a neurosteroid, e.g., allopregnanolone.

BACKGROUND

Steroids, including neurosteroids (e.g., allopregnanolone) are highlyinsoluble in aqueous solution. Various approaches are used to enhanceaqueous dissolution, including the use of cyclodextrin solutions.However, even with cyclodextrin as a solvation aid, solubility is notsufficient to permit systemic delivery for the treatment of medicalconditions.

SUMMARY

In one aspect, methods of preventing, treating, reducing, and/ormitigating one or more symptoms associated with and/or caused bytraumatic brain injury, Alzheimer's disease, epilepsy, anxiety, fragileX syndrome, post-traumatic stress disorder, lysosomal storage disorders(Niemann-Pick type C disease), depression (including post-partumdepression), premenstrual dysphoric disorder, alcohol craving, andsmoking cessation in a subject in need thereof are provided. In someembodiments, the methods comprise administering to the subject asteroid.

In another aspect, methods of preventing, treating, reducing, and/ormitigating symptoms associated with and/or caused by epilepsy, in asubject in need thereof are provided. In some embodiments, the methodscomprise administering to the subject a steroid.

In a further aspect, methods of accelerating the termination or abortionof an impending seizure in a subject in need thereof are provided. Insome embodiments, the methods comprise administering to the subject asteroid.

With respect to embodiments of the methods, in some embodiments, thesteroid is a neurosteroid. In some embodiments, the neurosteroid isselected from the group consisting of allopregnanolone,allotetrahydrodeoxycorticosterone, ganaxolone, alphaxolone, alphadolone,hydroxydione, minaxolone, and Althesin. In some embodiments, theneurosteroid is allopregnanolone. In some embodiments, the steroid isformulated in a cyclodextrin. In various embodiments, the steroid isformulated in hydroxypropyl-beta-cyclodextrin orsulfobutylether-beta-cyclodextrin sodium salt. In some embodiments, thesubject is experiencing aura. In some embodiments, the subject has beenwarned of an impending seizure. In some embodiments, the subject isexperiencing a seizure. In some embodiments, the subject has statusepilepticus. In some embodiments, the subject has myoclonic epilepsy. Insome embodiments, the subject suffers from seizure clusters. In someembodiments, the seizure is a tonic seizure. In some embodiments, theseizure is a clonic seizure. In some embodiments, the subject is ahuman. In some embodiments, the steroid is administered intramuscularly,intravenously or subcutaneously. In some embodiments, the methods entailtreating, reducing, and/or mitigating symptoms associated with and/orcaused by epilepsy by intramuscularly (i.m.), subcutaneously (s.c.) orintravenously (i.v.) administering allopregnanolone formulated in asulfobutylether-beta-cyclodextrin sodium salt. In some embodiments, theepilepsy is status epilepticus. In some embodiments, the steroid orneurosteroid (e.g., allopregnanolone) is administered at a dose in therange of about 0.25 mg/kg to about 15 mg/kg, e.g., about 0.25, 0.5, 1,2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 mg/kg. In someembodiments, the steroid or neurosteroid (e.g., allopregnanolone) isself-administered by the subject. In some embodiments, the steroid orneurosteroid (e.g., allopregnanolone) is administered by a caregiver whois not the subject.

In a further aspect, compositions comprising or consisting essentiallyof a steroid and a cyclodextrin are provided. In some embodiments, thesteroid is a neurosteroid. In some embodiments, the neurosteroid isselected from the group consisting of allopregnanolone,allotetrahydrodeoxycorticosterone, ganaxolone, alphaxolone, alphadolone,hydroxydione, minaxolone, and Althesin. In some embodiments, the steroidis allopregnanolone. In some embodiments, the cyclodextrin ishydroxypropyl-beta-cyclodextrin, sulfobutylether-beta-cyclodextrinsodium salt, or mixture thereof. In some embodiments, the compositioncomprises allopregnanolone and sulfobutylether-beta-cyclodextrin sodiumsalt.

In some embodiments, the steroid or neurosteroid (e.g.,allopregnanolone) is administered or formulated for administration viaan inhaler. In some embodiments, the steroid or neurosteroid (e.g.,allopregnanolone) is nebulized or aerosolized. In some embodiments, thesteroid or neurosteroid (e.g., allopregnanolone) is nebulized oraerosolized without heating. In some embodiments, the nebulized oraerosolized steroid or neurosteroid (e.g., allopregnanolone) particleshave a mass median aerodynamic diameter (“MMAD”) of about 5 μm orsmaller. In some embodiments, the nebulized or aerosolized steroid orneurosteroid (e.g., allopregnanolone) particles have a mass medianaerodynamic diameter (“MMAD”) of about 2-3 μm. In some embodiments, thesteroid or neurosteroid (e.g., allopregnanolone) is delivered to thedistal alveoli.

Definitions

As used herein, “administering” refers to local and systemicadministration, e.g., including enteral, parenteral, pulmonary, andtopical/transdermal administration. Routes of administration for steroidor neurosteroids (e.g., allopregnanolone) that find use in the methodsdescribed herein include, e.g., oral (per os (P.O.)) administration,nasal, inhalation or intrapulmonary administration, administration as asuppository, topical contact, transdermal delivery (e.g., via atransdermal patch), intrathecal (IT) administration, intravenous (“iv”)administration, intraperitoneal (“ip”) administration, intramuscular(“im”) administration, or subcutaneous (“sc”) administration, or theimplantation of a slow-release device e.g., a mini-osmotic pump, a depotformulation, etc., to a subject. Administration can be by any routeincluding parenteral and transmucosal (e.g., oral, nasal, vaginal,rectal, or transdermal). Parenteral administration includes, e.g.,intravenous, intramuscular, intra-arterial, intradermal, subcutaneous,intraperitoneal, intraventricular, ionophoretic and intracranial. Othermodes of delivery include, but are not limited to, the use of liposomalformulations, intravenous infusion, transdermal patches, etc.

The terms “systemic administration” and “systemically administered”refer to a method of administering a compound or composition to a mammalso that the compound or composition is delivered to sites in the body,including the targeted site of pharmaceutical action, via thecirculatory system. Systemic administration includes, but is not limitedto, oral, intranasal, rectal and parenteral (e.g., other than throughthe alimentary tract, such as intramuscular, intravenous,intra-arterial, transdermal and subcutaneous) administration.

The term “co-administration” refers to the presence of both activeagents in the blood at the same time. Active agents that areco-administered can be delivered concurrently (i.e., at the same time)or sequentially.

The phrase “cause to be administered” refers to the actions taken by amedical professional (e.g., a physician), or a person controllingmedical care of a subject, that control and/or permit the administrationof the steroid or neurosteroid (e.g., allopregnanolone) to the subject.Causing to be administered can involve diagnosis and/or determination ofan appropriate therapeutic or prophylactic regimen, and/or prescribingparticular steroid or neurosteroid (e.g., allopregnanolone) for asubject. Such prescribing can include, for example, drafting aprescription form, annotating a medical record, and the like.

The term “effective amount” or “pharmaceutically effective amount” referto the amount and/or dosage, and/or dosage regime of one or more steroidor neurosteroid (e.g., allopregnanolone) necessary to bring about thedesired result e.g., an amount sufficient prevent, abort or terminate aseizure.

As used herein, the terms “treating” and “treatment” refer to delayingthe onset of, retarding or reversing the progress of, reducing theseverity of, or alleviating or preventing either the disease orcondition to which the term applies, or one or more symptoms of suchdisease or condition.

The terms “reduce,” “inhibit,” “relieve,” “alleviate” refer to thedetectable decrease in the frequency, severity and/or duration ofseizures. A reduction in the frequency, severity and/or duration ofseizures can be measured by self-assessment (e.g., by reporting of thepatient) or by a trained clinical observer. Determination of a reductionof the frequency, severity and/or duration of seizures can be made bycomparing patient status before and after treatment.

The term “mitigating” refers to reduction or elimination of one or moresymptoms of that pathology or disease, and/or a reduction in the rate ordelay of onset or severity of one or more symptoms of that pathology ordisease (e.g., seizures), and/or the prevention of that pathology ordisease.

As used herein, the phrase “consisting essentially of” refers to thegenera or species of active pharmaceutical agents (e.g., neurosteroid,e.g., allopregnanolone) and excipient (e.g.,hydroxypropyl-beta-cyclodextrin or Captisol(sulfobutylether-beta-cyclodextrin sodium salt)) included in a method orcomposition. In various embodiments, other unmentioned or unrecitedactive ingredients and inactive are expressly excluded. In variousembodiments, additives (e.g., surfactants, acids (organic or fatty),alcohols, esters, co-solvents, solubilizers, lipids, polymers, glycols)are expressly excluded.

The terms “subject,” “individual,” and “patient” interchangeably referto a mammal, preferably a human or a non-human primate, but alsodomesticated mammals (e.g., canine or feline), laboratory mammals (e.g.,mouse, rat, rabbit, hamster, guinea pig) and agricultural mammals (e.g.,equine, bovine, porcine, ovine). In various embodiments, the subject canbe a human (e.g., adult male, adult female, adolescent male, adolescentfemale, male child, female child) under the care of a physician or otherhealthworker in a hospital, psychiatric care facility, as an outpatient,or other clinical context. In certain embodiments the subject may not beunder the care or prescription of a physician or other healthworker.

The term “neuroactive steroid” or “neurosteroid” refers to steroidcompounds that rapidly alter neuronal excitability through interactionwith neurotransmitter-gated ion channels. Neurosteroids act asallosteric modulators of neurotransmitter receptors, such as GABA_(A),NMDA, and sigma receptors. Neurosteroids find use as sedatives for thepurpose of general anaesthesia for carrying out surgical procedures, andin the treatment of epilepsy and traumatic brain injury. Illustrativeneurosteroids include, e.g., allopregnanolone, Ganaxolone, alphaxolone,alphadolone, hydroxydione, minaxolone, and Althesin (a mixture ofalphaxolone and alphadolone).

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates a time course for protection by allopregnanolone(5α,3α-P) administered i.v. at a doses of 1.5 and 0.5 mg/kg respectivelyin the 6-Hz electrical-stimulation (32 mA, 3 s) model. The intervalbetween the steroid injection and the electrical stimulus is plotted onthe abscissa and the percentage of animals protected against seizures isplotted on the ordinate. Each point represents eight mice.

FIG. 2 illustrates a time course for protection by allopregnanolone(5α,3α-P) administered i.m. at a doses of 6, 3, 1.5 mg/kg in the 6-Hzelectrical stimulation (32 mA, 3 s) model. The interval between thesteroid injection and the electrical stimulus is plotted on the abscissaand the percentage of animals protected against seizures is plotted onthe ordinate. Each point represents at least eight mice.

FIG. 3 illustrates a time course for protection by allopregnanolone(5α,3α-P) administered s.c. at a doses of 6 and 1.5 mg/kg in the 6-Hzelectricalstimulation (32 mA, 3 s) model. The interval between thesteroid injection and the electrical stimulus is plotted on the abscissaand the percentage of animals protected against seizures is plotted onthe ordinate. Each point represents eight mice.

FIG. 4 illustrates a time course for protection by allopregnanolone(5α,3α-P) administered p.o. at a dose of 300 and 200 mg/kg (doublevolume of 150 mg/kg and 100 mg/kg suspended/diluted in Canola oil) inthe 6-Hz electrical-stimulation (32 mA, 3 s) model. The interval betweenthe steroid injection and the electrical stimulus is plotted on theabscissa and the percentage of animals protected against seizures isplotted on the ordinate. Each point represents at seven to eight mice.

FIG. 5 illustrates the effect of i.v. administration of allopregnanolone(5α,3α-P) (0.1-1.5 mg/kg) on the onset of myoclonic jerk, generalizedclonus, and tonic extension in response to PTZ (80 mg/kg, i.p.)injection in mice. 5α,3α-P was administered i.v. 1 min before PTZinjection. Bars indicate mean S.E.M. of values from eight mice. p<0.05compared with vehicle control group (ANOVA followed by Dunnett's test).

FIG. 6 illustrates the effect of i.v. administration of allopregnanolone(5α,3α-P) (0.1-1.5 mg/kg) on the onset of myoclonic jerk, generalizedclonus, and tonic extension in response to PTZ (80 mg/kg, i.p.)injection in mice. 5α,3α-P was administered i.v. 2 min before PTZinjection. Bars indicate mean S.E.M. of values from eight mice. p<0.05compared with vehicle control group (ANOVA followed by Dunnett's test).

FIG. 7 illustrates the effect of i.v. administration of allopregnanolone(5α,3α-P) (0.25-1.5 mg/kg) on the onset of myoclonic jerk, generalizedclonus, and tonic extension in response to PTZ (80 mg/kg, i.p.)injection in mice. 5α,3α-P was administered i.v. 30 min before PTZinjection. Bars indicate mean S.E.M. of values from eight mice. p<0.05compared with vehicle control group (ANOVA followed by Dunnett's test).

FIG. 8 illustrates the effect of i.m. administration of allopregnanolone(5α,3α-P) (0.25-1.5 mg/kg) on the onset of myoclonic jerk, generalizedclonus, and tonic extension in response to PTZ (80 mg/kg, i.p.)injection in mice. 5α,3α-P was administered i.m. 2 min before PTZinjection. Bars indicate mean S.E.M. of values from at least seven mice.p<0.05 compared with vehicle control group (ANOVA followed by Dunnett'stest).

FIG. 9 illustrates the effect of i.m. administration of allopregnanolone(5α,3α-P) (0.25-1.5 mg/kg) on the onset of myoclonic jerk, generalizedclonus, and tonic extension in response to PTZ (80 mg/kg, i.p.)injection in mice. 5α,3α-P was administered i.m. 30 min before PTZinjection. Bars indicate mean S.E.M. of values from eight mice. p<0.05compared with vehicle control group (ANOVA followed by Dunnett's test).

FIG. 10 illustrates a Time-concentration profile for plasmaallopregnanolone (5α,3α-P) after single i.v. injection in rats. Ratsbearing indwelling jugular catheters received single i.v. injection of5α,3α-P or vehicle and serial blood samples were withdrawn at 1, 2, 10,15, 30, 60 and 120 min after injection. Plasma was assayed for 5α,3α-Pby LC-MS. Each point represents at least 4 animals.

DETAILED DESCRIPTION 1. Introduction

Treatment of status epilepicus requires rapid administration ofanti-seizure agents, which are typically delivered either by theintravenous (IV) or intramuscular (IM) routes. Allopregnanolone(3α-hydroxy-5α-pregnan-20-one; 5α,3α-P), an endogenousprogesterone-derived steroid that is a positive allosteric modulator ofGABA_(A) receptors, is a powerful anti-seizure agent with potential inthe treatment of status epilepticus. The present study determines anddemonstrates the dosing of allopregnanolone to protect against seizureswhen delivered intravenously (i.v.), intramuscularly (i.m.),subcutaneously (s.c.) or orally (p.o.).

2. Subjects Who can Benefit

In various embodiments, the subject has a condition that can be treatedor mitigated by administration of a neurosteroid, e.g.,allopregnanolone. Allopregnanolone has many medical uses, including thetreatment, reduction, and/or mitigation of symptoms associated withand/or caused by traumatic brain injury, Alzheimer's disease, epilepsy,anxiety, fragile X syndrome, post-traumatic stress disorder, lysosomalstorage disorders (Niemann-Pick type C disease), depression (includingpost-partum depression), premenstrual dysphoric disorder, alcoholcraving, and smoking cessation. The subject may or may not be exhibitingsymptoms.

Accordingly, the invention also contemplates methods of treating,reducing, and/or mitigating symptoms associated with and/or caused bytraumatic brain injury, Alzheimer's disease, epilepsy, anxiety, fragileX syndrome, post-traumatic stress disorder, lysosomal storage disorders(Niemann-Pick type C disease), depression (including post-partumdepression), premenstrual dysphoric disorder, alcohol craving, andsmoking cessation by administration of a steroid or neurosteroid (e.g.,allopregnanolone) dissolved or suspended in a vehicle suitable forsystemic administration (e.g., intramuscular, intravenous,subcutaneous), as described herein.

In some embodiments, the subject has epilepsy, has a history ofsuffering from epileptic seizures or is suffering from epilepticseizures. In various embodiments, the patient may be experiencing anelectrographic or behavioral seizure or may be experiencing a seizureaura, which itself is a localized seizure that may spread and become afull blown behavioral seizure. For example, the subject may beexperiencing aura that alerts of the impending onset of a seizure orseizure cluster.

Alternatively, the subject may be using a seizure prediction device thatalerts of the impending onset of a seizure or seizure cluster.Implantable seizure prediction devices are known in the art anddescribed, e.g., in D'Alessandro, et al., IEEE TRANSACTIONS ONBIOMEDICAL ENGINEERING, VOL. 50, NO. 5, May 2003, and U.S. PatentPublication Nos. 2010/0198098, 2010/0168603, 2009/0062682, and2008/0243022.

The subject may have a personal or familial history of any of theepileptic conditions described herein. The subject may have beendiagnosed as having any of the epileptic conditions described herein. Insome embodiments, the subject has or is at risk of suffering a myoclonicseizure or myoclonic epilepsy, e.g., juvenile myoclonic epilepsy. ThePTZ seizure model demonstrated herein is predictive of utility and/oractivity in counteracting myoclonic seizures or myoclonic epilepsy inhumans.

In various embodiments, the subject may be at risk of exposure to or mayhave been exposed to a nerve agent or a pesticide that can causeseizures. Illustrative nerve agents that can cause seizures include,e.g., organophosphorus nerve agents, e.g., tabun, sarin, soman, GF, VRand/or VX. Illustrative pesticides that can cause seizures include,e.g., organophosphate pesticides (e.g., Acephate (Orthene),Azinphos-methyl (Gusathion, Guthion), Bensulide (Betasan, Lescosan),Bomyl (Swat), Bromophos (Nexion), Bromophos-ethyl (Nexagan), Cadusafos(Apache, Ebufos, Rugby), Carbophenothion (Trithion), Chlorethoxyfos(Fortress), Chlorfenvinphos (Apachlor, Birlane), Chlormephos (Dotan),Chlorphoxim (Baythion-C), Chlorpyrifos (Brodan, Dursban, Lorsban),Chlorthiophos (Celathion), Coumaphos (Asuntol, Co-Ral), Crotoxyphos(Ciodrin, Cypona), Crufomate (Ruelene), Cyanofenphos (Surecide),Cyanophos (Cyanox), Cythioate (Cyflee, Proban), DEF (De-Green), E-Z-OffD), Demeton (Systox), Demeton-S-methyl (Duratox, Metasystoxl), Dialifor(Torak), Diazinon, Dichlorofenthion, (VC-13 Nemacide), Dichlorvos (DDVP,Vapona), Dicrotophos (Bidrin), Dimefos (Hanane, Pestox XIV), Dimethoate(Cygon, DeFend), Dioxathion (Delnav), Disulfoton (Disyston), Ditalimfos,Edifenphos, Endothion, EPBP (S-seven), EPN, Ethion (Ethanox), Ethoprop(Mocap), Ethyl parathion (E605, Parathion, thiophos), Etrimfos (Ekamet),Famphur (Bash, Bo-Ana, Famfos), Fenamiphos (Nemacur), Fenitrothion(Accothion, Agrothion, Sumithion), Fenophosphon (Agritox,trichloronate), Fensulfothion (Dasanit), Fenthion (Baytex, Entex,Tiguvon), Fonofos (Dyfonate, N-2790), Formothion (Anthio), Fosthietan(Nem-A-Tak), Heptenophos (Hostaquick), Hiometon (Ekatin), Hosalone(Zolone), IBP (Kitazin), Iodofenphos (Nuvanol-N), Isazofos (Brace,Miral, Triumph), Isofenphos (Amaze, Oftanol), Isoxathion (E-48,Karphos), Leptophos (Phosvel), Malathion (Cythion), Mephosfolan(Cytrolane), Merphos (Easy Off-D, Folex), Methamidophos (Monitor),Methidathion (Supracide, Ultracide), Methyl parathion (E601, Penncap-M),Methyl trithion, Mevinphos (Duraphos, Phosdrin), Mipafox (Isopestox,Pestox XV), Monocrotophos (Azodrin), Naled (Dibrome), Oxydemeton-methyl(Metasystox-R), Oxydeprofos (Metasystox-S), Phencapton (G 28029),Phenthoate (Dim ephenthoate, Phenthoate), Phorate (Rampart, Thimet),Phosal one (Azofene, Zolone), Phosfolan (Cylan, Cyolane), Phosmet(Imidan, Prolate), Phosphamidon (Dimecron), Phostebupirim (Aztec),Phoxim (Baythion), Pirimiphos-ethyl (Primicid), Pirimiphos-methyl(Actellic), Profenofos (Curacron), Propetamphos (Safrotin), Propylthiopyrophosphate (Aspon), Prothoate (Fac), Pyrazophos (Afugan,Curamil), Pyridaphenthion (Ofunack), Quinalphos (Bayrusil), Ronnel(Fenchlorphos, Korlan), Schradan (OMPA), Sulfotep (Bladafum, Dithione,Thiotepp), Sulprofos (Bolstar, Helothion), Temephos (Abate, Abathion),Terbufos (Contraven, Counter), Tetrachlorvinphos (Gardona, Rabon),Tetraethyl pyrophosphate (TEPP), Triazophos (Hostathion), andTrichlorfon (Dipterex, Dylox, Neguvon, Proxol).

3. Steroids

The compositions generally comprise or consist essentially of a steroid,e.g., a neurosteroid, suspended or dissolved in vehicle appropriate forsystemic administration, e.g., a cyclodextin, e.g.,hydroxypropyl-beta-cyclodextrin or sulfobutylether-beta-cyclodextrinsodium salt, or mixtures thereof.

In various embodiments the neurosteroid is allopregnanolone (ALP).Allopregnanolone, also known as 3α-hydroxy-5α-pregnan-20-one or3α,5α-tetrahydroprogesterone, IUPAC name1-(3-Hydroxy-10,13-dimethyl-2,3,4,5,6,7,8,9,11,12,14,15,16,17-tetradecahydro-1H-cyclopenta[a]phenanthren-17-yl)ethanone,and referenced as CAS number 516-54-1, is a prototypic neurosteroidpresent in the blood and also the brain. It is a metabolite ofprogesterone and modulator of GABA_(A) receptors. Whileallopregnanolone, like other GABA_(A) receptor active neurosteroids suchas allotetrahydrodeoxycorticosterone (3α,21-dihydroxy-5α-pregnan-20-one;THDOC), positively modulates all GABA_(A) receptor isoforms, thoseisoforms containing δ-subunits exhibit greater magnitude potentiation.Allopregnanolone has pharmacological properties similar to otherpositive modulators of GABA_(A) receptors, including anxiolytic andanticonvulsant activity. Allopregnanolone is neuroprotective in manyanimal models of neurodegenerative conditions, including, e.g.,Alzheimer's disease (Wang et al., Proc Natl Acad Sci USA. 2010 Apr. 6;107(14):6498-503), cerebral edema (Limmroth et al., Br J Pharmacol. 1996January; 117(1):99-104) and traumatic brain injury (He et al., RestorNeurol Neurosci. 2004; 22(1):19-31; and He, et al., Exp Neurol. 2004October; 189(2):404-12), Mood disorders (Robichaud and Debonnel, Int JNeuropsychopharmacol. 2006 April; 9(2):191-200), Niemann-Pick type Cdisease (Griffin et al., Nat Med. 2004 July; 10(7):704-11) and acts asan anticonvulsant against chemically induced seizures, including thepentylenetetrazol (PTZ) model (Kokate et al., J Pharmacol Exp Ther. 1994September; 270(3):1223-9). The chemical structure of allopregnanolone isdepicted below in Formula I:

In various embodiments, the compositions comprise a sulfate, salt,hemisuccinate, nitrosylated, derivative or congener of allopregnanolone.

Other neurosteroids that can be formulated in vehicle suitable forsystemic administration, include without limitationallotetrahydrodeoxycorticosterone (3α,21-dihydroxy-5α-pregnan-20-one;THDOC), 3α,21-dihydroxy-5b-pregnan-20-one, pregnanolone(3α-hydroxy-5(3-pregnan-20-one), Ganaxolone (INN, also known asCCD-1042; IUPAC name (3α,5α)-3-hydroxy-5-methylpregnan-20-one,1-[(3R,5S,8R,9S,10S,13S,14S,17S)-3-hydroxy-3,10,13-trimethyl-1,2,4,5,6,7,8,9,11,12,14,15,16,17-tetradecahydrocyclopenta[a]phenanthren-17-yl]ethanone),alphaxolone, alphadolone, hydroxydione, minaxolone, and Althesin (amixture of alphaxolone, alphadolone, tetrahydrodeoxycorticosterone,pregnenolone, dehydroepiandrosterone (DHEA), 7-substitutedbenz[e]indene-3-carbonitriles (see, e.g., Hu, et al., J Med Chem. (1993)36(24):3956-67); 7-(2-hydroxyethyl)benz[e]indene analogues (see, e.g.,Han, et al., J Med Chem. (1995) 38(22):4548-56); 3 alpha-hydroxy-5alpha-pregnan-20-one and 3 alpha-hydroxy-5 beta-pregnan-20-one analogues(see, e.g., Han, et al., J Med Chem (1996) 39(21):4218-32); enantiomersof dehydroepiandrosterone sulfate, pregnenolone sulfate, and(3alpha,5beta)-3-hydroxypregnan-20-one sulfate (see, e.g., Nilsson, etal., J Med Chem. (1998) 41(14):2604-13); 13,24-cyclo-18,21-dinorcholaneanalogues (see, e.g., Jiang, et al., J Med Chem. (2003) 46(25):5334-48);N-acylated 17a-aza-D-homosteroid analogues (see, e.g., Covey, et al., JMed Chem. (2000) 43(17):3201-4); 5 beta-methyl-3-ketosteroid analogues(see, e.g., Zeng, et al., J Org Chem. (2000) 65(7):2264-6);18-norandrostan-17-one analogues (see, e.g., Jiang, et al., J Org Chem.(2000) 65(11):3555-7); (3alpha,5alpha)- and(3alpha,5beta)-3-hydroxypregnan-20-one analogs (see, e.g., Zeng, et al.,J Med Chem. (2005) 48(8):3051-9); benz[f]indenes (see, e.g., Scaglione,et al., J Med Chem. (2006) 49(15):4595-605); enantiomers of androgens(see, e.g., Katona, et al., Eur J Med Chem. (2008) 43(1):107-13);cyclopenta[b]phenanthrenes and cyclopenta[b]anthracenes (see, e.g.,Scaglione, et al., J Med Chem. (2008) 51(5):1309-18);2beta-hydroxygonane derivatives (see, e.g., Wang, et al., Tetrahedron(2007) 63(33):7977-7984); Δ16-alphaxalone and corresponding17-carbonitrile analogues (see, e.g., Bandyopadhyaya, et al., Bioorg MedChem Lett. (2010) 20(22):6680-4); Δ(16) and Δ(17(20)) analogues ofΔ(16)-alphaxalone (see, e.g., Stastna, et al., J Med Chem. (2011)54(11):3926-34); neurosteroid analogs developed by CoCensys (now PurdueNeuroscience) (e.g., CCD-3693, Co2-6749 (a.k.a., GMA-839 andWAY-141839); neurosteroid analogs described in U.S. Pat. No. 7,781,421and in PCT Patent Publications WO 2008/157460; WO 1993/003732; WO1993/018053; WO 1994/027608; WO 1995/021617; WO 1996/016076; WO1996/040043, as well as salts, hemisuccinates, nitrosylated, sulfatesand derivatives thereof.

In various embodiments, the steroid or neurosteroid is not a sexhormone. In various embodiments, the steroid or neurosteroid is notprogesterone.

As appropriate, the steroid or neurosteroid (e.g., allopregnanolone) mayor may not be micronized. As appropriate, the steroid or neurosteroid(e.g., allopregnanolone) may or may not be enclosed in microspheres insuspension in the oil.

4. Formulation and Administration

In varying embodiments, the steroid and/or an analog thereof can beadministered systemically, e.g., intramuscularly (IM), or depo-IM,subcutaneously (SQ), and depo-SQ), as appropriate or desired. In varyingembodiments, the dosage form is selected to facilitate delivery to thebrain (e.g., passage through the blood brain barrier). In this contextit is noted that the steroids or neurosteroids (e.g., allopregnanolone)described herein can be readily delivered to the brain. Dosage formsknown to those of skill in the art are suitable for delivery of thesteroid.

Compositions are provided that contain therapeutically effective amountsof the steroid or neurosteroid (e.g., allopregnanolone). The steroids orneurosteroids (e.g., allopregnanolone) are preferably formulated intosuitable pharmaceutical preparations such as tablets, capsules, orelixirs for oral administration or in sterile solutions or suspensionsfor parenteral administration. Typically the steroids or neurosteroids(e.g., allopregnanolone) described above are formulated intopharmaceutical compositions using techniques and procedures well knownin the art.

These steroids or neurosteroids (e.g., allopregnanolone) or analogsthereof can be administered in the “native” form or, if desired, in theform of salts, esters, amides, prodrugs, derivatives, and the like,provided the salt, ester, amide, prodrug or derivative is suitablepharmacologically effective, e.g., effective in the present method(s).Salts, esters, amides, prodrugs and other derivatives of the activeagents can be prepared using standard procedures known to those skilledin the art of synthetic organic chemistry and described, for example, byMarch (1992) Advanced Organic Chemistry; Reactions, Mechanisms andStructure, 4th Ed. N.Y. Wiley-Interscience.

Methods of formulating such derivatives are known to those of skill inthe art. For example, the disulfide salts of a number of delivery agentsare described in PCT Publication WO 2000/059863 which is incorporatedherein by reference. Similarly, acid salts of therapeutic peptides,peptoids, or other mimetics, and can be prepared from the free baseusing conventional methodology that typically involves reaction with asuitable acid. Generally, the base form of the drug is dissolved in apolar organic solvent such as methanol or ethanol and the acid is addedthereto. The resulting salt either precipitates or can be brought out ofsolution by addition of a less polar solvent. Suitable acids forpreparing acid addition salts include, but are not limited to bothorganic acids, e.g., acetic acid, propionic acid, glycolic acid, pyruvicacid, oxalic acid, malic acid, malonic acid, succinic acid, maleic acid,fumaric acid, tartaric acid, citric acid, benzoic acid, cinnamic acid,mandelic acid, methanesulfonic acid, ethanesulfonic acid,p-toluenesulfonic acid, salicylic acid, orotic acid, and the like, aswell as inorganic acids, e.g., hydrochloric acid, hydrobromic acid,sulfuric acid, nitric acid, phosphoric acid, and the like. An acidaddition salt can be reconverted to the free base by treatment with asuitable base. Certain particularly preferred acid addition salts of theactive agents herein include halide salts, such as may be prepared usinghydrochloric or hydrobromic acids. Conversely, preparation of basicsalts of the active agents of this invention are prepared in a similarmanner using a pharmaceutically acceptable base such as sodiumhydroxide, potassium hydroxide, ammonium hydroxide, calcium hydroxide,trimethylamine, or the like. In certain embodiments basic salts includealkali metal salts, e.g., the sodium salt, and copper salts.

For the preparation of salt forms of basic drugs, the pKa of thecounterion is preferably at least about 2 pH lower than the pKa of thedrug. Similarly, for the preparation of salt forms of acidic drugs, thepKa of the counterion is preferably at least about 2 pH higher than thepKa of the drug. This permits the counterion to bring the solution's pHto a level lower than the pHmax to reach the salt plateau, at which thesolubility of salt prevails over the solubility of free acid or base.The generalized rule of difference in pKa units of the ionizable groupin the active pharmaceutical ingredient (API) and in the acid or base ismeant to make the proton transfer energetically favorable. When the pKaof the API and counterion are not significantly different, a solidcomplex may form but may rapidly disproportionate (e.g., break down intothe individual entities of drug and counterion) in an aqueousenvironment.

Preferably, the counterion is a pharmaceutically acceptable counterion.Suitable anionic salt forms include, but are not limited to acetate,benzoate, benzylate, bitartrate, bromide, carbonate, chloride, citrate,edetate, edisylate, estolate, fumarate, gluceptate, gluconate,hydrobromide, hydrochloride, iodide, lactate, lactobionate, malate,maleate, mandelate, mesylate, methyl bromide, methyl sulfate, mucate,napsylate, nitrate, pamoate (embonate), phosphate and diphosphate,salicylate and disalicylate, stearate, succinate, sulfate, tartrate,tosylate, triethiodide, valerate, and the like, while suitable cationicsalt forms include, but are not limited to aluminum, benzathine,calcium, ethylene diamine, lysine, magnesium, meglumine, potassium,procaine, sodium, tromethamine, zinc, and the like.

In various embodiments preparation of esters typically involvesfunctionalization of hydroxyl and/or carboxyl groups that are presentwithin the molecular structure of the active agent. In certainembodiments, the esters are typically acyl-substituted derivatives offree alcohol groups, e.g., moieties that are derived from carboxylicacids of the formula RCOOH where R is alky, and preferably is loweralkyl. Esters can be reconverted to the free acids, if desired, by usingconventional hydrogenolysis or hydrolysis procedures.

Amides can also be prepared using techniques known to those skilled inthe art or described in the pertinent literature. For example, amidesmay be prepared from esters, using suitable amine reactants, or they maybe prepared from an anhydride or an acid chloride by reaction withammonia or a lower alkyl amine.

Determination of an effective amount for administration in a singledosage is well within the capability of those skilled in the art,especially in light of the detailed disclosure provided herein.Generally, an efficacious or effective amount of the steroid orneurosteroid (e.g., allopregnanolone) is determined by firstadministering a low dose or small amount of the agent and thenincrementally increasing the administered dose or dosages, adding asecond or third medication as needed, until a desired effect of isobserved in the treated subject with minimal or no toxic side effects.Applicable methods for determining an appropriate dose and dosingschedule for administration of a combination of the present inventionare described, for example, in Brunton, et al., Goodman and Gilman's ThePharmacological Basis of Therapeutics, 12th Edition, 2010, McGraw-HillProfessional; in a Physicians' Desk Reference (PDR), 66^(th) Edition,2012; in Loyd, et al., Remington: The Science and Practice of Pharmacy,22^(st) Ed 2012, Pharmaceutical Press; in Martindale: The Complete DrugReference, Sweetman, 2005, London: Pharmaceutical Press, and inMartindale, Martindale: The Extra Pharmacopoeia, 31st Edition, 1996,Amer Pharmaceutical Assn, each of which are hereby incorporated hereinby reference. In various embodiments, the compositions are formulated,e.g., for oral administration, at a dose in the range of about 5 mg/kgto about 250 mg/kg of the steroid or neurosteroid (e.g.,allopregnanolone), e.g., about 5 mg/kg, 10 mg/kg, 15 mg/kg, 20 mg/kg, 25mg/kg, 30 mg/kg, 35 mg/kg, 40 mg/kg, 45 mg/kg, 50 mg/kg, 75 mg/kg, 100mg/kg, 125 mg/kg, 150 mg/kg, 200 mg/kg, or 250 mg/kg.

About 1 to 1000 mg of a steroid or neurosteroid (e.g.,allopregnanolone), or a physiologically acceptable salt or ester iscompounded with a physiologically acceptable vehicle, carrier,excipient, binder, preservative, stabilizer, flavor, etc., in a unitdosage form as called for by accepted pharmaceutical practice. Theamount of active substance in those compositions or preparations is suchthat a suitable dosage in the range indicated is obtained. Thecompositions are preferably formulated in a unit dosage form, eachdosage containing from about 1-1000 mg, 2-800 mg, 5-500 mg, 10-400 mg,50-200 mg, e.g., about 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg,40 mg, 45 mg, 50 mg, 60 mg, 70 mg, 80 mg, 90 mg, 100 mg, 200 mg, 300 mg,400 mg, 500 mg, 600 mg, 700 mg, 800 mg, 900 mg or 1000 mg of the activeingredient. In varying embodiments, the steroid or neurosteroid (e.g.,allopregnanolone) is administered systemically (e.g., intramuscularly,intravenously, subcutaneously) at a dose in the range of about 0.25mg/kg to about 15 mg/kg, e.g., about 0.25 mg/kg to about 15 mg/kg, e.g.,about 0.25, 0.5, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15mg/kg. The term “unit dosage from” refers to physically discrete unitssuitable as unitary dosages for human subjects and other mammals, eachunit containing a predetermined quantity of active material calculatedto produce the desired therapeutic effect, in association with asuitable pharmaceutical excipient.

In varying embodiments, the steroids or neurosteroids (e.g.,allopregnanolone) are formulated for intrapulmonary administration. Invarious embodiments, the steroids or neurosteroids (e.g.,allopregnanolone) are formulated for delivery via an inhaler.

In various embodiments, the steroids or neurosteroids (e.g.,allopregnanolone) are nebulized. Methods and systems for intrapulmonarydelivery of steroids or neurosteroids (e.g., allopregnanolone) are knownin the art and find use. Illustrative systems for aerosol delivery ofsteroids or neurosteroids (e.g., allopregnanolone) by inhalation aredescribed, e.g., in U.S. Pat. Nos. 5,497,763; 5,660,166; 7,060,255; and7,540,286; and U.S. Patent Publication Nos. 2003/0032638; and2006/0052428, each of which are hereby incorporated herein by referencein their entirety for all purposes. Preferably, the steroids orneurosteroids (e.g., allopregnanolone) are nebulized without the inputof heat.

For administration of the nebulized and/or aerosolized steroids orneurosteroids (e.g., allopregnanolone), the size of the aerosolparticulates can be within a range appropriate for intrapulmonarydelivery, particularly delivery to the distal alveoli. In variousembodiments, the aerosol particulates have a mass median aerodynamicdiameter (“MMAD”) of less than about 5 μm, 4 μm, 3 μm, for example,ranging from about 1 μm to about 3 μm, e.g., from about 2 μm to about 3μm, e.g., ranging from about 0.01 μm to about 0.10 μm. Aerosolscharacterized by a MMAD ranging from about 1 μm to about 3 μm candeposit on alveoli walls through gravitational settling and can beabsorbed into the systemic circulation, while aerosols characterized bya MMAD ranging from about 0.01 μm to 0.10 μm can also be deposited onthe alveoli walls through diffusion. Aerosols characterized by a MMADranging from about 0.15 μm to about 1 μm are generally exhaled. Thus, invarious embodiments, aerosol particulates can have a MMAD ranging from0.01 μm to about 5 μm, for example, ranging from about 0.05 μm to about3 μm, for example, ranging from about 1 μm to about 3 μm, for example,ranging from about 0.01 μm to about 0.1 μm. The nebulized and/oraerosolized steroids or neurosteroids (e.g., allopregnanolone) can bedelivered to the distal alveoli, allowing for rapid absorption andefficacy.

In various embodiments, the steroids or neurosteroids (e.g.,allopregnanolone) is formulated in a solution comprising excipientssuitable for aerosolized intrapulmonary delivery. The solution cancomprise one or more pharmaceutically acceptable carriers and/orexcipients. Pharmaceutically acceptable refers to approved or approvableby a regulatory agency of the Federal or a state government or listed inthe U.S Pharmacopoeia or other generally recognized pharmacopoeia foruse in animals, and more particularly in humans. Preferably, thesolution is buffered such that the solution is in a relatively neutralpH range, for example, a pH in the range of about 4 to 8, for example, apH in the range of about 5-7. In some embodiments, the steroids orneurosteroids (e.g., allopregnanolone) is formulated in a bufferedsolution, for example, phosphate-buffered saline.

In various embodiments, the steroids or neurosteroids (e.g.,allopregnanolone) is prepared as a concentrated aqueous solution.Ordinary metered dose liquid inhalers have poor efficiency for thedelivery to the deep lung because the particle size is not sufficientlysmall (Kim et al., 1985 Am Rev Resp Dis 132:137-142; and Farr et al.,1995 Thorax 50:639-644). These systems are therefore used mostly forlocal delivery of drugs to the pulmonary airways. In addition, metereddoses inhalers may not be able to deliver sufficient volumes of even aconcentrated steroids or neurosteroids (e.g., allopregnanolone) solutionto produce the desired rapid antiseizure effect. Accordingly, in variousembodiments, a metered doses inhaler is not used for delivery of thesteroids or neurosteroids (e.g., allopregnanolone). In one embodiment anebulization system with the capability of delivering <5 μm particles(e.g., the PARI LC Star, which has a high efficiency, 78% respirablefraction 0.1-5 μm. see, e.g., pari.com) is used for intrapulmonaryadministration. Electronic nebulizers which employ a vibrating mesh oraperture plate to generate an aerosol with the required particle sizecan deliver sufficient quantities rapidly and find use (See, e.g., Knochand Keller, 2005 Expert Opin Drug Deliv 2: 377-390). Also,custom-designed hand-held, electronic nebulizers can be made and finduse.

Aerosolized delivery of steroids or neurosteroids (e.g.,allopregnanolone) allows for reduced dosing to achieve desired efficacy,e.g., in comparison to intravenous or intranasal delivery. Appropriatedosing will depend on the size and health of the patient and can bereadily determined by a trained clinician. Initial doses are low andthen can be incrementally increased until the desired therapeutic effectis achieved with little or no adverse side effects. In variousembodiments, the steroids or neurosteroids (e.g., allopregnanolone) areadministered via the intrapulmonary route at a dose that is about 10%,15%, 25%, 50% or 75% of established doses for their administration viaother routes (e.g., via oral, intravenous or intranasal administration).In some embodiments, the steroids or neurosteroids (e.g.,allopregnanolone) are administered via the intrapulmonary route at adose in the range of about 0.05 mg/kg to about 1.0 mg/kg, for example,about 0.2 mg/kg to about 0.8 mg/kg, for example, about 0.05 mg/kg, 0.08mg/kg, 0.1 mg/kg, 0.2 mg/kg, 0.3 mg/kg, 0.4 mg/kg, 0.5 mg/kg, 0.6 mg/kg,0.7 mg/kg, 0.8 mg/kg, 0.9 mg/kg, or 1.0 mg/kg. In some embodiments, thesteroids or neurosteroids (e.g., allopregnanolone) are administered viathe intrapulmonary route at a dose in the range of about 10 mg/kg toabout 80 mg/kg, for example, about 20 μg/kg to about 60 mg/kg, forexample, about 25 mg/kg to about 50 mg/kg, for example, about 10 mg/kg,15 mg/kg, 20 μg/kg, 25 μs/kg, 30 mg/kg, 35 μg/kg, 40 μg/kg, 45 μg/kg, 50μg/kg, 60 μs/kg, 70 μg/kg, or 80 μg/kg. In some embodiments, thesteroids or neurosteroids (e.g., allopregnanolone) are administered viathe intrapulmonary route at a dose in the range of about 0.3 mg/kg toabout 3.0 μg/kg.

To prepare compositions, the steroid or neurosteroid (e.g.,allopregnanolone) is mixed with a suitable pharmaceutically acceptablecarrier. Upon mixing or addition of the compound(s), the resultingmixture may be a solution, suspension, emulsion, or the like. Liposomalsuspensions may also be suitable as pharmaceutically acceptablecarriers. These may be prepared according to methods known to thoseskilled in the art. The form of the resulting mixture depends upon anumber of factors, including the intended mode of administration and thesolubility of the steroid or neurosteroid (e.g., allopregnanolone) inthe selected carrier or vehicle. The effective concentration issufficient for lessening or ameliorating at least one symptom of thedisease, disorder, or condition treated and may be empiricallydetermined.

Pharmaceutical carriers or vehicles suitable for administration of thesteroids or neurosteroids (e.g., allopregnanolone) provided hereininclude any such carriers known to those skilled in the art to besuitable for the particular mode of administration (e.g.,cyclodextrins). In addition, the active materials can also be mixed withother active materials that do not impair the desired action, or withmaterials that supplement the desired action, or have another action.The steroids or neurosteroids (e.g., allopregnanolone) may be formulatedas the sole pharmaceutically active ingredient in the composition or maybe combined with other active ingredients.

Where the steroids or neurosteroids (e.g., allopregnanolone) exhibitinsufficient solubility, methods for solubilizing may be used. Suchmethods are known and include, but are not limited to, using cosolventssuch as dimethylsulfoxide (DMSO), using surfactants such as Tween™, anddissolution in aqueous sodium bicarbonate. Derivatives of the steroidsor neurosteroids (e.g., allopregnanolone), such as salts or prodrugs mayalso be used in formulating effective pharmaceutical compositions.

The concentration of the steroid or neurosteroid (e.g.,allopregnanolone) is effective for delivery of an amount uponadministration that lessens or ameliorates at least one symptom of thedisorder for which the compound is administered and/or that is effectivein a prophylactic context. Typically, the compositions are formulatedfor single dosage (e.g., daily) administration.

The steroids or neurosteroids (e.g., allopregnanolone) may be preparedwith carriers that protect them against rapid elimination from the body,such as time-release formulations or coatings. Such carriers includecontrolled release formulations, such as, but not limited to,microencapsulated delivery systems. The active steroid or neurosteroid(e.g., allopregnanolone) is included in the pharmaceutically acceptablecarrier in an amount sufficient to exert a therapeutically useful effectin the absence of undesirable side effects on the patient treated. Thetherapeutically effective concentration may be determined empirically bytesting the steroids or neurosteroids (e.g., allopregnanolone) in knownin vitro and in vivo model systems for the treated disorder. Atherapeutically or prophylactically effective dose can be determined byfirst administering a low dose, and then incrementally increasing untila dose is reached that achieves the desired effect with minimal or noundesired side effects.

In various embodiments, the steroids or neurosteroids (e.g.,allopregnanolone) and/or analogs thereof can be enclosed in multiple orsingle dose containers. The enclosed compounds and compositions can beprovided in kits, for example, including component parts that can beassembled for use. For example, a compound inhibitor in lyophilized formand a suitable diluent may be provided as separated components forcombination prior to use. A kit may include a compound inhibitor and asecond therapeutic agent for co-administration. The inhibitor and secondtherapeutic agent may be provided as separate component parts. A kit mayinclude a plurality of containers, each container holding one or moreunit dose of the compounds. The containers are preferably adapted forthe desired mode of administration, including, but not limited to depotproducts, pre-filled syringes, ampules, vials, and the like forparenteral administration

The concentration and/or amount of steroid or neurosteroid (e.g.,allopregnanolone) in the drug composition will depend on absorption,inactivation, and excretion rates of the steroid or neurosteroid (e.g.,allopregnanolone), the dosage schedule, and amount administered as wellas other factors known to those of skill in the art.

The active ingredient may be administered at once, or may be dividedinto a number of smaller doses to be administered at intervals of time.It is understood that the precise dosage and duration of treatment is afunction of the disease being treated and may be determined empiricallyusing known testing protocols or by extrapolation from in vivo or invitro test data. It is to be noted that concentrations and dosage valuesmay also vary with the severity of the condition to be alleviated. It isto be further understood that for any particular subject, specificdosage regimens should be adjusted over time according to the individualneed and the professional judgment of the person administering orsupervising the administration of the compositions, and that theconcentration ranges set forth herein are exemplary only and are notintended to limit the scope or practice of the claimed compositions.

5. Monitoring Efficacy

In various embodiments, administration of a steroid or neurosteroid(e.g., allopregnanolone) to a subject results in the prevention ormitigation of one or more symptoms of the disease condition beingtreated (e.g., traumatic brain injury, Alzheimer's disease, epilepsy,anxiety, fragile X syndrome, post-traumatic stress disorder, lysosomalstorage disorders (Niemann-Pick type C disease), depression (includingpost-partum depression), premenstrual dysphoric disorder, alcoholcraving, and smoking cessation). Symptoms of disease can be comparedbefore and after administration of a steroid or neurosteroid (e.g.,allopregnanolone) to the subject. Administration of the steroid orneurosteroid (e.g., allopregnanolone) to the subject is considered to beeffective if the symptoms no longer occur after administration (e.g.,seizures), or if the symptoms are reduced, alleviated and/or mitigatedafter administration.

In various embodiments, administration of a steroid or neurosteroid(e.g., allopregnanolone) to a subject results in the prevention of theoccurrence of an impending seizure and/or the termination or abortion ofa seizure in progress.

In various embodiments, efficacy can be monitored by the subject. Forexample, in a subject experiencing aura or receiving a warning from aseizure prediction device, the subject can self-administer a dose of thesteroid or neurosteroid (e.g., allopregnanolone). If the steroid orneurosteroid (e.g., allopregnanolone) is administered in an efficaciousamount, the sensation of aura should subside and/or the seizureprediction device should no longer predict the imminent occurrence of animpending seizure. If the sensation of aura does not subside and/or theseizure prediction device continues to predict an impending seizure, asecond dose of steroid or neurosteroid (e.g., allopregnanolone) can beadministered.

In other embodiments, the efficacy is monitored by a caregiver. Forexample, in a subject experiencing the onset of a seizure or insituations where a seizure has commenced, the subject may requireadministration of the steroid or neurosteroid (e.g., allopregnanolone)by a caregiver. If the steroid or neurosteroid (e.g., allopregnanolone)is administered in an efficacious amount, the seizure, along with thesubject's symptoms of the seizure, should terminate or abort. If theseizure does not terminate, a second dose of the steroid or neurosteroid(e.g., allopregnanolone) can be administered.

EXAMPLES

The following examples are offered to illustrate, but not to limit theclaimed invention.

Example 1 Anticonvulsant Activity of Intravenous and IntramuscularAllopregnanolone

Rationale:

Treatment of status epilepicus requires rapid administration of antiseizure agents, which are typically delivered either by the intravenous(i.v.) or intramuscular (i.m.) routes. Allopregnanolone(3α-hydroxy-5α-pregnan-20-one; 5α,3α-P), an endogenousprogesterone-derived steroid that is a positive allosteric modulator ofGABA_(A) receptors, is a powerful antiseizure agent with potential inthe treatment of status epilepticus. The objective of this study was todetermine the dosing of allopregnanolone to protect against seizureswhen delivered i.v. and i.m.

Methods:

The mouse 6 Hz and pentylenetetrazol seizure models were used. Solutionsof 5α,3α-P were made in 6% (0.5 and 1.5 mg/ml)sulfobutylether-β-cyclodextrin sodium salt (Captisol®) in 0.9% saline.The solutions were injected i.v. or i.m. (1, 2 and 30 min or 2 and 30min, respectively) prior to administration of the 6 Hz electricalstimulus or PTZ (80 mg/kg, i.p.). In case of the PTZ model, animals wereobserved for 30 min and times to myoclonic jerks and clonic and tonicseizures were recorded. Anticonvulsant activity was assessed by thedelay in onset of seizure signs. Allopregnanolone plasma levels in ratswere determined by LC-MS.

Results:

5α,3α-P exhibited protective activity in the 6 Hz test 1-15 min afteri.v. infusion (1.5 mg/kg) but was inactive at 30 min. In contrast, withi.m. administration (3 mg/kg) the onset of protective activity wasslower (within 2 min) and lasted <2 h. At a dose of 0.1 mg/kg i.v.5α,3α-P failed to significantly delay seizure onset in the PTZ model atall pretreatment times (1, 2 and 30 min) whereas a dose of 0.5 mg/kgadministered 1 min before PTZ caused a marked delay for myoclonic jerksand clonic seizures and in 62.5% of animals prevented tonic seizures andmortality that invariably accompanies tonic seizures. When injected 2min before PTZ 5α,3α-P (0.5 mg/kg) caused a similar increase in time toonset of seizures signs and prevented tonic seizures in 25% of animals.

5α,3α-P at a dose of 1.5 mg/kg completely prevented tonic seizures andmortality when injected i.v. 1 and 2 min before PTZ. When injected i.m.2 min before PTZ, 0.25, 0.5 and 1.5 mg/kg 5α,3α-P protected 0%, 50% and100%, respectively, of animals from tonic seizures. 5α,3α-P at the doseof 1.5 mg/kg i.m. provided significant protection against tonic seizureswhen injected 30 min before PTZ; the same dose injected i.v. 30 minbefore PTZ was inactive. In rats, an i.v. bolus dose of 0.5 and 1.0mg/kg 5α,3α-P caused mean peak plasma levels (2 min) of 337 and 746ng/ml, respectively; for both doses, the pooled mean two componenthalftimes were 2 and 22 min.

Conclusions:

Our results demonstrate that i.v. 5α,3α-P provides very rapid buttransitory anticonvulsant activity. When injected i.m., 5α,3α-P actscomparably quickly and has a longer duration of action. Parenteral5α,3α-P may be useful for the acute treatment of seizures.

Detailed Methods

Animals.

Male NIH Swiss mice (22-30 g) served as subjects, and all proceduresused in these studies were conducted in accordance with the Universityof California, Davis, Institutional Animal Care and Use Committee theAnimal Care and Use policies in strict compliance with the Guide for theCare and Use of Laboratory Animals of the National Research Council(National Academy Press, Washington,D.C.; on the internet atnap.edu/readingroom/books/labrats/).

Test Substances and Drug Administration.

Allopregnanolone (3α-hydroxy-5α-pregnan-20-one; 5α,3α-P) was synthesizedby a SAFC Pharma Inc, Madison, Wis., USA and Captisol(sulfobutylether-beta-cyclodextrin sodium salt) was provided by LigandPharmaceuticals, Inc. La Jolla, Calif., USA. Solutions of 5α,3α-P weremade in 6% (0.5 and 1.5 mg/ml) or 24% (6 mg/kg)sulfobutylether-β-cyclodextrin sodium salt (Captisol®) in 0.9% saline.The volumes used for all injections were 10-20 ml/kg of body weight. Inorder to establish time courses for protection by 5α,3α-P in the 6-Hzelectrical-stimulation (32 mA, 3 s) model, 5α,3α-P (0.5-6 mg/kg) wasadministered intravenously (i.v.), intramuscularly (i.m.),subcutaneously (s.c.) or orally (p.o.) before electrical stimulation. Inthe PTZ seizure test, 5α,3α-P or vehicle were administered i.v. or i.m.1, 2 or 30 min before PTZ.

Seizures Models

6-Hz seizure test (Kaminski, et al., Epilepsia (2004) 45:1-4): 3-scorneal stimulation (200-μs duration, 32-mA monopolar rectangular pulsesat 6 Hz) was delivered by a constant-current device (ECT Unit 5780; UgoBasile, Comerio, Italy). After the stimulation, the animals exhibited a“stunned” posture associated with rearing and automatic movements thatlasted from 60 to 120 s in untreated animals. The experimental end pointwas protection against the seizure: an animal was considered to beprotected if it resumed its normal exploratory behavior within 10 s ofstimulation.

Pentylenetetrazol Seizure Test

(Kokate, et al., J Pharmacol Exp Ther (1994) 270:1223-9): mice wereinjected intraperitoneally with PTZ (80 mg/kg) and were observed for a30-min period. The time of onset of myoclonic jerks, clonus and tonicextension was recorded.

Surgery and Blood Collection.

Male rats were implanted with indwelling jugular catheters as described(Baumann, et al., J Neurosci. (1998) 18: 9069-77). Animals were allowedto recover for at least one week. Experiments were carried out while theanimal resided in its home cage. Rats received i.v. injection of vehicleor 5α,3α-P and serial blood samples were withdrawn into chilled tubes at1, 2, 10, 15, 30, 60 and 120 min after i.v. injection. 5α,3α-P andD4-5α,3α-P (internal standard) were extracted with SPE method from rat'splasma. The extracted 5α,3α-P and D4-5α,3α-P were quantified withultra-performance liquid chromatography (UPLC)/Atmospheric-pressurechemical ionization (APCI)/tandem mass spectrometry (MS/MS).

Data Analysis.

Results are expressed as mean±S.E.M.; the significance of the differencein the responses of treatment groups with respect to control is based onone-way analysis of variance (ANOVA) followed by specific post hoccomparisons using Dunnett's test. Differences were consideredstatistically significant when the probability of error was less than0.05 (p<0.05).

Results are shown in FIGS. 1-10. Our results demonstrate that i.v.5α,3α-P provides very rapid but transitory anticonvulsant activity. Wheninjected i.m., 5α,3α-P acts comparably quickly and has a longer durationof action. Low bioavailability of 5α,3α-P after oral administrationprolongs the time of the peak effect and duration of action. Parenteral5α,3α-P is useful for the acute treatment of seizures.

It is understood that the examples and embodiments described herein arefor illustrative purposes only and that various modifications or changesin light thereof will be suggested to persons skilled in the art and areto be included within the spirit and purview of this application andscope of the appended claims. All publications, patents, and patentapplications cited herein are hereby incorporated by reference in theirentirety for all purposes.

1.-21. (canceled)
 22. A composition comprising or consisting essentiallyof a steroid and a cyclodextrin.
 23. The composition of claim 22,wherein the steroid is a neurosteroid.
 24. The composition of claim 23,wherein the neurosteroid is selected from the group consisting ofallopregnanolone, allotetrahydrodeoxycorticosterone, ganaxolone,alphaxolone, alphadolone, hydroxydione, minaxolone, and Althesin. 25.The composition of any one of claims 22 to 24, wherein the steroid isallopregnanolone.
 26. The composition of any one of claims 22 to 25,wherein the cyclodextrin is hydroxypropyl-beta-cyclodextrin,sulfobutylether-beta-cyclodextrin sodium salt, or a mixture thereof. 27.The composition of any one of claims 22 to 26, wherein the compositionis formulated for intramuscular (i.m.), subcutaneous (s.c.) orintravenous (i.v.) administration.
 28. The composition of any one ofclaims 22 to 27, wherein the composition comprises allopregnanolone andsulfobutylether-beta-cyclodextrin sodium salt.